Forearm deviated inwards with
respect to arm at elbow with
resulting lateral angulation in full
Reduction of physiological valgus
8 ̊-15 ̊ ; Males : 10 ̊
Females : 15 ̊- 20 ̊
Normally forearm is aligned in valgus with
respect to arm in full extension with medial
Decrease in valgus with neutral alignment
(loss of angulation) is called “Cubitus Rectus”.
It is still a deformity as it deviates from the
normal for population.
Varus deformity at elbow
1. Post traumatic malunited s/c humerus fracture (most
2. Congenital (progressive)
3. Malunited fracture lateral condyle (progressive if due to
hyperemia and overgrowth)
4. Trochlear Osteonecrosis (static)
5. Malunited intercondylar fracture (static)
6. Malunited medial condyle fracture (static)
•Medial tilt and lateral angulation at elbow
•Prominence of lateral condyle humerus
•Wasting of muscles
• No local warmth/tenderness
•Thickening and irregularity of supracondylar ridges
• 3 point bony relationship maintained
• Medial epicondyle tip higher
• Hyperextension at elbow
• No widening of intercondylar region
• Internal rotation deformity with increased internal
rotation (Yamamoto test )
• Decreased external rotation which is compensated by
much more mobile shoulder joint (so often goes unnoticed
DISPLACEMENTS THAT OCCUR AT
“Gun-stock Deformity” – Looks
like a loading stock of old
long barrel guns
MEASUREMENTS ON XRAY :- AP VIEW
•Decrease in normal physiological valgus
•Increase in Baumann’sAngle
(Normal – 64 ̊to 81 ̊)
•Normally no overlap between the
lateral condylar epiphysis and
•If significant tilt of distal fragment
occurs, there is overlap between
the two which appears like a
crescent → ‘Crescent Sign”
TREATMENT :- 3 MODALITIES
1. Observation with expected remodeling
2. Hemiepiphysiodesis and growth alteration
3. Corrective osteotomy
Treatment is primarily “Cosmetic Correction”
•Generally not appropriate
•Because, although hyperextension may remodel in a young
child; in an older child, little remodeling occurs even in the
plane of function of the joint
•Hemiepiphysiodesis of distal humerus is rarely of value
•Only to prevent varus deformity with clear medial growth
arrest or trochlear osteonecrosis
•If untreated, deformity will progress because of medial
growth arrest and lateral overgrowth
•Lateral epiphysiodesis will not correct the deformity but
will prevent it from increasing
3. Corrective Osteotomy
1. Atleast 1 year following fracture (Bone
remodeling and tissue equilibrium)
2. Patient demanding surgery
3. Calculation of wedge to be
removed→Normal side Xray→
Wedge angle =Varus + Normal physiological
(Metal wedge autoclaved)
3 Basic Types
Lateral closing wedge osteotomy
Most stable inherently
Medial open wedge osteotomy with bone
Oblique osteotomy with derotation
Lateral closing wedge osteotomy (Voss et al.)
Standard preparation, draping,
Lateral incision at elbow
With fluoroscopic guidance, insert 2
K-wires into lateral condyle just
distal to the planned distal cut.
Advance proximally after making
wedge osteotomy closing laterally.
Keep medial cortex intact;
weaken it by multiple drill
holes and a Apply forceful
valgus stress to complete
the osteotomy .Close the
osteotomy and advance the
K-wires into the medial
cortex of proximal
fragment. Leave the wires
buried under the skin. A
third wire can be used if
necessary for stability.
Close the wound in layers;
splint the arm in 90 ̊ flexion
and full pronation.
•Lateral closing wedge osteotomy with 2 guide pins
and 2 screws inserted proximal and distal to the pins
parallel to them.
•Medial cortex broken
•Only periosteum intact
•Approximately the wedge till the 2 screws are
•Hold this position withTBW
French Osteotomy Modified French Osteotomy
Detach whole of triceps
Ulnar nerve explored
Medial cortex broken
Lateral half of triceps
Ulnar nerve Not explored
Medial cortex intact so
(DEROSA & GRAZIANO)
•A modification of lateral closing wedge osteotomy
•Using a template constructed preoperatively, make
a lateral closing wedge osteotomy in the
metaphyseal region superior to the olecranon fossa.
•Make the osteotomy leaving a lateral spike of bone
•Trim lateral portion of proximal fragment for close
•Correct the medial tilt, rotational malalignment,
hyperextension and fix with crossed K-wires
•Then, use a lag screw from lateral portion of distal
fragment to proximal fragment
•Close the wound and apply posterior splint for 4
STEP-CUT TRANSLATION OSTEOTOMY
WITH A Y-SHAPED HUMERAL PLATE
•Posterior approach to distal humerus.
•Incise the capsule to expose medial and lateral condyles
•Basic step-cut osteotomy involves osteotomy with a triangular template
0.5 cm proximal to olecranon fossa with base of triangle perpendicular to
humeral shaft and apex directed proximally.
•Remove wedge of bone.
•In cubitus varus, rotate distal fragment so as to fix its lateral border intoV-
shaped apex of proximal fragment.
•In cubitus valgus, do fit the medial border of distal
fragment into apex of proximal fragment leading to
lateralization of the apex.
•This basic step-cut translational osteotomy corrects
deformity only in coronal plane.
•Rotational deformity corrected in same operation by
excising a piece of bone from posterior aspect ofV-shaped
proximal fragment. Correct rotation when angle of rotation
differs by 10 ̊from normal.
•Temporarily fix the correction by K-wires. Smoothen the
sharp edges of medial and lateral columns.
•Fix with 3.5mm plate with 5 screws distally and 2 screws
OBLIQUE OSTEOTOMY WITH DEROTATION
(AMSPACHER & MESSENBAUGH)
•Patient prone and pneumatic tourniquet in place.
•Posterior elbow exposure through a longitudinal incision; divide triceps in
line with its muscle fibres, expose the s/c part of humerus subperiosteally
protecting the radial and ulnar nerves.
•Oscillating saw used to make an oblique osteotomy about 3.8cm proximal
to distal end of humerus directing it posteriorly above to anteriorly below.
Complete it anteriorly with osteotome.Tilt and rotate the distal fragment
until cubitus varus and internal rotation have been corrected.
•With fragments in position, fix them with a screw inserted across the
middle of osteotomy.
•Arm is immobilized in a long arm cast or splint until union at 4-6 weeks.
DOME OSTEOTOMY WITH
(UCHIDA ET AL)
•A type of osteotomy with derotation
• Preferred in mild cubitus varus
•2 semicircular cuts made from lateral to medial
•2 domes rotated and aligned to correct the
•Corrects lateral prominence of condyle
MEDIAL OPEN WEDGE OSTEOTOMY WITH BONE
(KING & SECOR)
•Gains length→ inherent instability
•May stretch the ulnar nerve- transferred anteriorly to avoid this